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UIC Application forFellowship/ResidencyPGYI hereby apply for clinical graduate training in atyear level, tobegin .PERSONAL INFORMATION1. Name(Last)(First)3. Citizenship USA Other:4. Date of Birth6. Gender9. Present Address5. Place of Birth7. University ID Number (UIN)* Male Female Non-Binary(Street)(City)10. Telephone Number2. Social Security Number(Middle)(State)(City)(State)(Country)8. Nat’l Provider Identifier (NPI)**(Zip)(Country)(Zip)(Country)11. Personal Email Address12. Permanent Address (Street)(City)(State)VISA STATUS (if applicable)13. Current Visa Status Permanent Resident Alien J-1 J-2 H-1B F-1 Other (be specific): O-1 Asylee/Asylum Temporary Protected Status (TPS)Yes or No: My current visa status includes an Employment Authorization Document (EAD)14. Expected Visa Status Permanent Resident Alien J-1 J-2 H-1B F-1(OPT) Other (be specific): O-1 Asylee/Asylum Yes No Temporary Protected Status (TPS)Yes or No: My expected visa status will require an Employment Authorization Document (EAD) Yes NoUIC Application — Page 1 of 6* A UIN is an identification number specific to the University of Illinois system. A UIN is issued to all U of I students, employees and some temporary visitors.** Information about applying for & updating an NPI Identity & Access User ID will be forwarded to incoming residents & fellows as part of the onboarding process.
Applicant Name:MEDICAL/DENTAL EDUCATION15. Medical/Dental School(Name)(City)16. Date of Matriculation(State/Country)17. Date of Graduation8. Prior Medical/Dental School (if applicable)(Name)(City)(State/Country)(Dates Attended)RESIDENCY/FELLOWSHIP HISTORYSpecialtyInstitutionLocationDates ServedECFMG Registration/Certification (if applicable)19. ECFMG No.20. ECFMG Issue DateEXAMINATION SCORESExam NameDateScoreUSMLE STEP 1USMLE STEP 2-CKUSMLE Step 2-CSUSMLE Step 3COMLEX LEVEL 1COMLEX LEVEL 2-CECOMLEX LEVEL 2-PECOMLEX LEVEL 3UIC Application — Page 2 of 6City/State# of Attempts
Applicant Name:GRADUATE EDUCATIONGraduate e(if any)Area of StudyUNDERGRADUATE EDUCATIONUndergraduate SchoolName/City/State/CountryStart DateEnd DateDegree(if any)MajorRECORD OF MEDICAL/DENTAL LICENSUREList all medical and/or dental licenses issued to you since receiving your medical/dental degree.Include licenses not issued in the United States.LicenseState/CountryLicense #Issue DateExp.DateOriginal LicenseCurrent LicenseOther LicenseOther LicenseOther LicenseHave you ever been denied a license, permit, or privilege of taking an examination by any licensingauthority? If yes, attach a detailed explanation. Yes NoHave you ever had a license or permit encumbered in any way (revoked, suspended, surrendered,censored, restricted, limited, placed on probation)? If yes, attach a detailed explanation. Yes NoHave you ever been named in a malpractice suit? If yes, attach a detailed explanation. Yes NoHave you ever been convicted of any criminal offense in any state or in federal court (other than minortraffic violations)? If yes, attach statement including date and place of conviction(s) and nature of suchoffense(s). Yes NoUIC Application — Page 3 of 6
Applicant Name:PERSONAL STATEMENT(Use additional sheet, if necessary)UIC Application — Page 4 of 6
Applicant Name:LETTERS OF REFERENCEList the name, title and institution of those you have requested to write in your behalf.A minimum of three letters are required.Signed, original letters—or electronically signed letters--are required. Letters of recommendation must be submitted by the sourcedirectly to the UIC training program, and must be not be older than a year.Name & TitleRef. #1Institution (Name, City, State/Country)Ref. #2Ref. #3Ref. #4Check One: I hereby waive access to the above letters and will so inform the authors. I desire access to the above letters and will so inform the authors.STATE OF HEALTHDo you have any condition that would preclude you from forming rational judgments, reacting quicklyin emergent situations, or working for an extended period of time (i.e., night call) under stressfulconditions without interruption? If yes, attach a detailed explanation. Yes NoSERVICE OBLIGATIONS(Military Service, National Health Service Corps, Armed Forces Scholarship, State Programs, Etc.) I am not required to fulfill any service obligations. I am committed to fulfill a service obligation beginning . No. of years committed:APPLICANT SIGNATUREI certify that the information on this application is complete and correct to the best of my knowledge.I understand that any false or missing information may disqualify me for this training position or begrounds for termination in case of employment.Name of ApplicantSignatureDateThis application is intended to be completed, signed and submitted electronically.You may also print the form and submit the signed & dated original.UIC Application — Page 5 of 6Applicant Name:
UIC Residency/Fellowship File RequirementsA complete UIC/GME resident application file consists of the documents listed below. Please note: the UIC Officeof Graduate Medical Education (GME) will not begin processing a resident file or is a UIC Resident Agreementuntil documents #1-9 are on file in the GME office.Required Application DocumentReceivedReceivedDate1. Residency Application2. Curriculum Vitae (CV)3. Personal Statement4. USMLE Score Sheets or Transcript (Steps 1, 2-CK and 2-CS; or equiv., e.g., COMLEX, NBDE)5. ECFMG Certificate (International Medical School Graduates Only)6. Medical / Dental School Diploma7. Dean’s Letter (aka “Principal’s Letter”)8. Medical / Dental School Transcript9. Three Letters of Recommendation 1 – Last Name: 2 – Last Name: 3 – Last Name:1:2:3:10. Letter of Good Standing* (if applicable)11. Verification of Prior Training* (if applicable)* NOTE: The applicant cannot be involved in the process of requesting or submitting a Letter of Good Standing and/orVerification of Prior Training. This documentation must be sent directly from the current or prior trainingprogram to the UIC training program to which the applicant has been accepted.[01/22/2020]UIC Application — Page 6 of 6
A complete UIC/GME resident application file consists of the documents listed below. Please note: the UIC Office of Graduate Medical Education (GME) will not begin processing a resident file or is a UIC Resident Agreement until documents #1 -9 are on file in the GME office.
